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General NPI Number Information
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NPI Number | 1184765125
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Entity Type | Individual
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Provider Name | STEPHEN MIKSIC PH.D.
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Gender | Male
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Dates
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Enumeration Date | 02/11/2007
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Last Update Date | 12/21/2022
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Provider Practice Location Address
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Address Line | 35 PRINCETON RD
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City | HAVERTOWN
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State | PA
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Zip | 19083-3621
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Country | US
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Telephone | 610-584-9721
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Fax | 610-584-9721
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Provider Business Mailing Address
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Address Line | 32799 OCEAN REACH DR
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City | LEWES
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State | DE
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Zip | 19958-4663
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Country | US
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Telephone | 610-716-6590
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Fax | 302-200-7432
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TF0200X
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Taxonomy Name | Forensic Psychologist
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License Number | PS004073L
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License Number State | PA
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